TABLE 1.

Guidelines for use of propranolol in infantile hemangiomas (IHs)

Oral propranolol in head and neck IHs
Indications
IH with functional consequences (visual axis obstruction, stridor, feeding difficulties)
Large segmental IH (including PHACE syndrome)
Localized IH at risk of permanent disfigurement (including ulceration)
Prior therapy
Search for contraindication: careful questioning and clinical examination
Routine echocardiography and electrocardiogram are not necessary if basic cardiologic examination is normal
Electrocardiogram and cardiologic visit required in case of bradycardia and/or arrythmia at auscultation
Initiation and monitoring
Treatment should be initiated only in clinical setting equipped and qualified for the safe and immediate management of any adverse event (e.g., bradycardia)
Initial dosage of 1 mg/kg/day bid the first week, then increase to 2 to 3 mg/kg/d the following weeks
Monitoring of 2 h after the first intake and at each dosage increase
Maintain 2 to 3 mg/kg/day, bid for 6 to 12 months
Monitor children monthly: clinical evaluation + pictures
End of treatment: tapering is not necessary
Parents should be informed of the risk of relapse (10% to 15% of cases)
Expected side effects
At each visit, parents should be educated concerning the risk of hypoglycemia and respiratory symptoms (wheezing)
To avoid hypoglycemia, be sure that the infant feeds regularly; in case of poor food intake temporarily stop propranolol; in case of wheezing, also temporarily stop propranolol
Minor side effects: nothing to do in case of cold hands or asymptomatic low diastolic blood pressure; for nightmares avoid giving the treatment after 5 pm and/or reduce the dosage